Children's Questionnaire
The Insititure for Neuro-Physiological Psychology
Date of Birth *
MM
/
DD
/
YYYY
Address *
Your answer
Email Address *
Your answer
Name of Child: *
Your answer
Telephone *
Your answer
Is your child currently taking any prescribed medication? Please specify:
Your answer
Has a diagnosis been given at any time i.e. Dyslexia, Dyspraxia, ADHD? If so, please state:
Your answer
Parent/Guardian
Your answer
What investigations/interventions has your child received in the past?
Your answer
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